NUTRITION DISORDERS

DR MBURU
CLINICAL PHARMACIST
TYPES OF MALNUTRITION

 Over-nutrition
 Secondary malnutrition

 Micronutrient malnutrition

 Protein Calorie malnutrition

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 A) OVER-NUTRITION

 Too many calories leading to obesity, diabetes,

hypertension and cardiovascular disease

 Obesity- When a persons body mass index is 30 or greater.

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B) SECONDARY MALNUTRITION

 Condition that prevents proper digestion or absorption

 Often accompanies and exacerbates other types of

malnutrition

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SECONDARY MALNUTRITION-
CAUSATIVE CONDITIONS
 Loss of appetite
 Alteration of normal metabolism

 during infection/fever
 HIV/AIDS
 Prevention of nutrient absorption

 Diarrheal infection causing changes in GI epithelium

 Diversion of nutrients to parasitic agents themselves

 Hookworms, tapeworms, schistosomes worm

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CHILDREN WITH INTESTINAL
PARASITES
(COURTESY OF WHO)

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PREVENTION OF NUTRIENT DIVERSION

 Sanitary waste disposal and clean water important in reducing

secondary malnutrition
 Preventionof transmission of parasites and diarrheal diseases
 Hookworm acquired by walking barefoot over contaminated soil
 Other roundworm infestation use oral-fecal route

 Soap an important factor in nutritional status

 Education of women extremely important in this regard

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C) MICRONUTRIENT MALNUTRITION
 Dietary Deficiencies of
 Vitamin A
 Iodine
 Iron
 Others: Zinc, vitamins D, C, and Bs

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D) PROTEIN ENERGY MALNUTRITION
(PEM)

 PEM: Invariably reflects combined deficiencies in protein,

energy and micronutrients

 Kwashiorkor and marasmus are 2 forms of PEM.

 The distinction between the 2 forms of PEM is based on the

presence (kwashiorkor) or absence (marasmus) of edema.

 Marasmus involves inadequate intake of protein and calories,

whereas a child with kwashiorkor has fair-to-normal calorie
intake with inadequate protein intake. 9
 ROLE OF CALORIES

 Involuntary use: breathing, blood circulation, digestion,

maintaining muscle tone and body temperature
 Physical activity

 Mental activity

 Fighting disease

 Growth

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 ROLE OF PROTEIN

 For building cells that make up muscles, membranes, cartilage and

hair
 Carrying oxygen

 Nutrient transport

 Antibodies

 Enzymes needed for most chemical reactions in the body

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WHAT HAPPENS TO PEOPLE WHEN THEY
HAVE INADEQUATE AMOUNTS OF FOOD
AND NUTRIENTS?

 Metabolic changes
 Physiologic changes

 Psychological changes

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METABOLIC RESPONSE TO STARVATION

 Hunger subsides after 2-3 days

 Defecation ceases after 3-4 days

 Urine output drops after 1 week in the majority of people to 100-

700 ml/day
 Blood glucose levels drop to 35 to 65 mg/dl without clinical
signs of hypoglycemia
 Nausea occurs in about 1/3 from ketone production from body
fat breakdown

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METABOLIC RESPONSE TO STARVATION
 Serum electrolytes do not change
 Renal conservation occurs promptly
 Rarely see low potassium in prolonged fast

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METABOLIC RESPONSE TO STARVATION
 Negative nitrogen balance - First 5 to 7 days
 12 to 15 grams of nitrogen per day is excreted in the urine
(based on 1800 kcal daily needs)
 Skeletal muscle is catabolized to produce glucose
(gluconeogenesis), using about 75 grams per day of protein
 This is equal to ¾ lb of wet tissue per day

 About 160 gm per day of body fat is also used

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METABOLIC RESPONSE TO STARVATION
 Negative nitrogen balance
 Gradually slows so that at about 1 month
 2-4 grams of nitrogen is loss per day

 Skeletal muscle catabolism decrease significantly

 Only for cells that have to have glucose

Central nervous system

Red blood cells

White blood cells

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METABOLIC RESPONSE TO STARVATION

 Gradual shift in metabolic fuels

 First glucose is produced from protein breakdown to provide
energy
 Then fat breakdown and metabolism provides ketones for all
tissues except CNS, RBC and WBC
 Brain will eventually use ketones but red blood cells have no
mitochondria, so must use glucose
 Serum fatty acid levels increase
 Serum albumin is normal until late in starvation

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PRODUCTION OF KETONES

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METABOLISM

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METABOLIC RESPONSE TO STARVATION

 Hormonal changes
 Plasma insulin decreases
 Plasma cortisol and growth hormone stay the same and glucagon
increases
 These changes are responsible for the mobilization and oxidation of
fat stores
 Changes in sympathetic nervous system and metabolism of thyroid
hormone lowers basal metabolic rate

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METABOLIC RESPONSE TO STARVATION
 Weight loss
 Firstweek 0.7 to 1.3 kg per day, much of which is slat and water loss
 After the first week 0.3 to 0.5 kg/day

 Basal Metabolic Rate and Total Energy Expenditure decrease in

prolonged starvation
 Seedecreased activity, increased sleep
 Decrease in body temperature

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 KWASHIORKOR
 Kwashiorkor results from lack of protein in diet.
 It is caused by inadequate protein intake in the presence of
fair to good energy intake
 Kwashiorkor is characterized by marked muscle atrophy with
normal or increased body fat.

Age:- * Mainly 6months → 3years.

Aetiology:-
General causes: - Maternal ignorance, Poverty.
Dietetic errors: Excess starchy feeding.
Infections: Diarrhea, Measles, T.B.
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KWASHIORKOR MANIFESTATIONS
 Normal or nearly normal weight and height for age
 Anasarca
 Rounded prominence of the cheeks ("moon-face")
 Pursed appearance of the mouth
 Pitting edema in the lower extremities and periorbitally
 Dermatoses: Dry, atrophic, peeling skin with confluent areas
of hyperkeratosis and hyperpigmentation
 Dry, dull, hypopigmented hair that falls out or is easily
plucked
 Hepatomegaly (from fatty liver infiltrates)
 Distended abdomen with dilated intestinal loops
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Complications of kwashiorkor:-
a) Infections:
1- Bronchopneumonia is the most common cause of death.
2- Others: otitis media, UTI, TB, monilial infections.
3- Gastroenteritis: diarrhea, malabsorption and dehydration.

b) Hypoglycemia.

c) Heart failure: due to:

1- Anaemia.
2- Volume overload (fluid or blood).
3- Weak myocardial contractility.

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MARASMUS

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 MARASMUS
 It is a state of chronic malnutrition due to deficiency of total
caloric requirements.

 Commonly seen in the first 2 years of life.

 Marasmus is characterized by the wasting of muscle mass and

the depletion of body fat stores.

 Classically, children with marasmus have severe constipation

and are ravenously hungry.

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ETIOLOGY:-
1. Socio-economic causes : Ignorance, poverty, depression.

2. Dietetic errors (nutritional marasmus):

- Scanty breast milk (in amount or number of feeds).
- Small amount of feed.
- Delayed weaning.
- Over dilutional formula in artificial feeding.
- Cow`s milk protein allergy.

3. Non-dietetic errors (secondary marasmus) :

- Gastroenteritis.
-Malabsorption syndromes.
- Infections: T.B, pyelonephritis, chronic suppurative lung disease.
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4. Congenital abnormalities:
- G.I.T.:- congenital pyloric stenosis, cleft lip and palate.
- Liver:- congenital hepatic cirrhosis.
- CVS:- fallots tetralogy,
- Chest :- congenital interstitial fibrosis.
- Renal:- renal agenesis, obstructive uropathy.
-CNS:- defective cerebral development.

5. Metabolic disorders:
- Renal tubular acidosis, Fructosemia, Urea cycle defects, Galactosemia,
Amino acid defects.

6. Endocrinal disorders:
- Juvenile D.M, Adrenal insufficiency.
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Clinical picture of marasmus:-
Growth failure:
1- At first, there is failure to gain weight then loss of weight occurs.
2- Weight less than 60% of the ideal weight for age.

Loss of subcutaneous fat:

1- First degree: loss of subcutaneous fat in the abdominal wall.
2- Second degree: loss of subcutaneous fat in limbs, buttocks and
abdominal wall.
3- Third degree: loss of subcutaneous fat in face limbs and abdominal.

Muscle wasting:- Detected by decreased mid-arm circumference.

Marked pallor due to associated anemia.

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Subnormal temperature due to loss of subcutaneous fat.

Gastro-intestinal manifestations:
1- Anorexia
2- Constipation .
3- Diarrhea due to gastroenteritis and malabsorption

Signs of vitamin deficiencies.

Infections:- Pneumonia, Gastroenteritis, Otitis media, U.T.I and

T.B.

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…MARASMUS
Complications:-
Oedema:- marasmus kwashiorkor.
DIC.
Pressure sores.
Fatal hypothermia

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MARASMIC KWASHIORKOR:
 The marasmic kwashiorkor form of edematous protein-
energy malnutrition is characterized by clinical features
of both types of malnutrition.

 It can occur in prolonged protein malnutrition, when loss

of subcutaneous tissue, muscle mass, and adipose stores
also is prominent.

 The main features are the edema of kwashiorkor, with or

without skin lesions, and the cachexia of marasmus
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DIAGNOSIS OF PEM
 Nutritional assessment is the quantitative evaluation of
nutritional status.
 A comprehensive nutritional assessment has four
components:
 Dietary, medical, and medication history
 Physical examination
 Growth and anthropometric measurements
 Laboratory tests

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MANAGEMENT OF P.E.M.
Management of simple undernutrition:

1. Can be managed at home without hospital admission.

2. Diet should provide:120-150 kcal/ kg / day, proteins: 2-4 gm/ day.

3. Frequency:- Small frequent feeds (every 2-4 hours).

4. Types of foods which can be used:

- Choose suitable, locally available, economically feasible weaning foods
as milk, eggs, cereals, vegetables, beans and if feasible animal proteins.

5. Regular follow up of weight is very important.

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Treatment of the complications.
1. Treatment of dehydration:
-ORS is the golden treatment for dehydration due to P.E.M. we must avoid I.V.
fluid therapy as possible for the risk of heart failure due to overload except
if there is shock. -
The recommended regimen for the treatment of dehydration due to
malnutrition as follow:
- ORS given slowly: in amount of 70-100 ml / kg over 12 hours.
- At the first 2 hours, the patient receives 10 ml / kg.
- The remaining amount given over the following 10 hours.
- Add 50-100 ml after each watery stool.

-I.V. fluids: ringers lactate plus glucose in a percentage of 1:1 and add 2.5 ml
of 15% kcl for each one litter. 

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..COMPLICATIONS RX
2. Treatment of infections:
- Appropriate antibiotics even if the signs of infection is not
present.
- In manifest infection:- according to culture and sensitivity.

3. Treatment of electrolyte disturbances:

- Hypoglycemia:- glucose 10% 2 ml / kg I.V. and regular
feeding.
- Hypocalcemia:- Ca gluconate 10% slowly I.V (2ml / kg).
-Hypokalemia:- Add K to the I.V. fluids (2mEq / kg).

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..COMPLICATIONS RX
4. Treatment of hypothermia-
-Proper wrappings or Put under warmth.

5. Treatment of anaemia:
If severe give:
- Fresh blood in amount of 20 ml / kg. - Fresh packed
RBCs in case of anaemic heart failure in amount of 5-10
ml / kg.
- Fresh frozen plasma 10 ml / kg in case of
hypoprothrombinemia .
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..COMPLICATIONS RX
Dietetic management
Route:- Oral or Nasogastric tube.
- Small feeds (every 2-3 hours).
- Half strength and half amount in the first 2days then
increased gradually until we reach full strength .
- Start with 120-150 kcal / kg / day, and after 1-2 weeks we
increase calories gradually up to 200 kcal / kg / day.

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..COMPLICATIONS RX
Food used in management:
- Milk, yoghurt, rice, beans, lentils, fish, meat, eggs and
chicken.
- Oils, sugar may be added for food to increase calories
content.

Vitamins and minerals:

- Vitamin A, vitamin D and vitamin B complex.
- Calcium, zinc and iron.

If no satisfactory response to good dietary management, look

for: Hidden infections as U.T.I. or Hidden disease as
anaemia, Coronary heart disease and, metabolic disorders.
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PREVENTION OF PEM:
1. Breast milk feeding promotion.
2. Proper weaning.
3. Early detection of P.E.M. by using weight charts and
MAC.
4. Immunization.
5. Control of most common diseases such as diarrhea.
6. Food supplementation programmes:
- Iron to treat anaemia.
-Iodine to treat and prevent hypothyroidism.
7. Health education
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